Managed care gets thumbs down from just about any audience

March 31, 1998|By Ellen Goodman

BOSTON -- Too bad they don't have an Oscar for the Single Best Line in a movie. A Zeitgeist award for the sentence you want to freeze-frame, the magical moment when Hollywood fantasy meets daily life, when they get it absolutely right.

Helen Hunt and Jack Nicholson picked up a couple of statues last week for Best Actress and Best Actor in "As Good as It Gets." But the Best Line prize belongs to the scribbler who put a string of ungenteel words in Ms. Hunt's mouth. When the distraught mother gave her opinion about the managed medical attention being given her asthmatic son, she exploded: "F HMO B Pieces of S-!"

At this outburst -- with none of the expletives deleted -- audiences all over America spontaneously burst out into applause. It was one of those moments when you know the tide has turned.

HMOs have become the new expletive undeleted. Managed care companies are rapidly replacing tobacco companies as corporate demons. Indeed if you watch "The Rainmaker," the HMOs are taking the place of the Russkies as the bad guys. As Ronald Glasser, a Minneapolis pediatrician, HMO critic and moviegoer who was downing popcorn when the audience roared at Ms. Hunt, exclaims, "I looked around and said, 'My God, the people are way ahead of the politicians on this.' "

A few years ago, the public saw doctors as rich professionals who overcharged on Tuesday and played golf on Wednesday. The weakness in the system was cost control, or cost out of control.

Now doctors and consumers are becoming allies on the same side, fighting the HMOs, hassling the 800 numbers, trapped in a medical system we suspect is being run by accountants. The weakness in the system is trust. Or rather, mistrust.

Poll results

It is an astonishingly swift transformation. Bob Blendon, who polls health care issues at Harvard School of Public Health, is about to publish a study of the consumer backlash, which confirms Helen Hunt's less professorial opinion. His survey of surveys proves, "We have changed the whole politics of the health field. Essentially patients and doctors have come together in a new class of exploited people."

These two views seem contradictory, but the backlash is based jTC on the widespread anxiety about what happens if they get sick. "People have come to believe," says Mr. Blendon, "that these plans won't do the right thing for them when they are very sick."

Polls show that most Americans are satisfied with their own health care plans, but they favor some type of government regulation.

There isn't much objective research to show how often health care is refused or how often the hassles and hurdles have lethal consequences. The backlash is driven by horror stories of health care plans that won't pay for emergency care, by anecdotes of cancer referrals denied or delayed.

We have gotten the big picture as well. About 15 percent of the population accounts for 80 percent of the medical bills. In the phrase Mr. Glasser used in the March issue of Harper's, HMOs are "a Ponzi scheme" in which the premiums have to keep ahead of claims.

But the backlash scenario presents the HMOs with a dilemma. On the one hand, employers and employees may choose a system based on how it treats the very ill. On the other hand, HMOs want to enroll the very healthy.

Lacking PR skills

In general, managed care companies have shown the public relations skills of independent counsel Kenneth Starr. In the past year or so, we've had massive reports of outpatient breast surgery and drive-through deliveries. In return we get HMO defensiveness.

Politicians who read the papers and go to the movies are playing catch-up. About 1,000 bills have been filed in state legislatures to protect the consumers from the managers.

In Washington, Congress is still dithering around with various forms of a Patient's Bill of Rights, with Republican leadership trying to stall, duck and weave. But it is getting pushed closer to a law that would provide for an external appeal to those denied care, access to emergency room, and an ombudsman program.

As for the HMOs? Those folks who brought us Harry and Louise, are now warning us about Frankenstein. The latest ads say, "Washington: Be careful how you play doctor, you might mandate a monster."

A monster? It's the unmandated, unregulated system that has now produced the horror movie running in everybody's head. Any way you look at health care, even in a darkened theater, this is not as good as it gets.